canvas adaptive 05/26/2020
A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, which factor should the nurse consider?
Crying releases tension and frees psychic energy for coping. Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping
edema scale
1+ 2mm 2+ 4mm 3+ 6mm 4+ 8mm
folk health belief system
Belief that health and illness are controlled by supernatural forces. May use native healers, plants, religious rituals, and prayers.
muscular dystrophy
group of hereditary diseases characterized by degeneration of muscle and weakness
nosocomial infection
hospital acquired infection infection causes diarrhea and abdominal discomfort
diuresis
increased output of urine
thrombophlebitis
inflammation of a vein associated with a clot formation
lorazepam
is a prescription medical treatment used to manage anxiety -should slowly arise from supine to sitting or standing position -may cause orthostatic hypotension
puritus
itching
The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? (Select all that apply.)
-flushed face -increased pulse rate
What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply.
Pruritis Wheezing Bronchospasm
The registered nurse (RN) is planning to provide feedback to the licensed practical nurse(LPN). Which questions asked by the RN help in eliciting the LPN's work quality? Select all that apply.
"how did the patient respond?" "what changes were observed in the client?"
The registered nurse us teaching a novice nurse about the rights of delegation. which statement by the nurse indicated a need for further teaching?
- " i will instruct the delegatee to monitor and evaluate the client appropriately
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma?
Acetazolamide (Diamox) -It is a carbonic anhydrase inhibitor that decreases inflow of aqueous humor and controls intraocular pressure in acute angle-closure glaucoma attack
A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first?
Elevate the head of the bed, provide reassurance, and reassess the blood pressure
aorta
Largest artery in the body
situational-contingency theory
Leadership in any given situation depends on the power of the leader, the nature of the task, and the relationship between the leader and the team members
Clostridium difficile
Oral metronidazole; if refractory, oral vancomycin
esophagoenterostomy.
Removal of portion of esophagus with segment of colon attached to remaining portion
Tretralogy of Fallot
Tetralogy of Fallot is a combination of four congenital abnormalities. The four defects include a ventricular septal defect (VSD), pulmonary valve stenosis, a misplaced aorta and a thickened right ventricular wall (right ventricular hypertrophy)
dyphasia
difficulty speaking
PYREXIA
fever
ileal conduit
urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall
Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure?
-dilation of blood vessels -paralysis of the vasomotor nerves after spinal anesthetic results in dilation of blood vessels which causes a decreases in blood pressure
Albuterol
Bronchodilator S/S: tachcardia, palpitations, tremors
Maslow's Heirarchy of Human Needs
Maslow's hierarchy of needs is a charted set of human requirements that are important for an individual to achieve complete development and self-actualization. ... The levels of the hierarchy, starting from the base of the pyramid are: Physiological needs - These are biological requirements for human survival.
style theory
This concentrates on two types of leadership: task- or production and people- or relationship-oriented leadership.
A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity?
- blowing nose
patients with thrombocytopenia are at greater risk for what?
- excessive bleeding in response to minimal trauma
A client has a bone marrow aspiration performed. After the procedure, what is the first nursing action?
-Briefly apply pressure over the aspiration site.
A NURSE IS CARING FOR FOUR CLIENTS. WHICH CLIENT WILL MOST LIKELY REQUIRE PALLIATIVE CARE AND MANAGEMENT WITH HYDRATION, ANALGESICS, AND OXYGEN THERAPY?
-a client with vasoocclusive crisis
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?
-arterial blood gas this tests allows for evaluation of gas exchanges in the lungs
To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.)
-encourage ambulation -auscultate bowel sounds monitoring bowel sounds will provide info about peristalsis ambulation stimulates peristalsis increases passage of flatus and decrease distention
Hospice Medicare Benefit
Covers all expenses for palliative care related to the terminal illness, including professional staff visits, medication, equipment, and respite and acute care
Muslim
Death: Family contacted before any care of deceased is performed Dietary habits: Refuse pork, cornbread, collard greens, other traditional black culture foods Other: Quiet time necessary to permit prayer, encouraged to use black physicians for health care
hypoxia
Low oxygen saturation of the body, not enough oxygen in the blood
segmental postural drainage
Postural drainage is generally performed for three to five minutes on each segment. During this time, the person being treated should take slow, deep breaths followed by a vigorous coughing to help clear mucus
The nurse manager is teaching the nursing team about funds allocated to health departments for personal health services by local, state, and federal governments. Which statement made by a member of the team would indicate effective learning? Select all that apply.
The funds provide care for newborns." "The funds provide care for clients with tuberculosis." "The funds provide care for children with birth defects
impaired psychomotor functions
The term "psychomotor" refers to the connections made between mental and muscle functions
After assessing a victim of a bomb blast that has caused mass casualties, the emergency department nurse applies a black band to the hand. What is the rationale behind this nursing action?
The victim has severe head injury and requires artificial ventilation
indwelling cather
catheter that remains inside the bladder for a period of time
pulmonary embolism
clot or other material lodges in vessels of the lung
hemiplegia
paralysis of one side of the body
aphasic
without speech
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason?
- to reduce edema at the operative site this position prevents fluid accumulation, which minimizes edema
a physician in a hospital decides to practice defensive medicine. when would a physcian practice defensive medicine?
- when the physician is overly cautious about the fear of malpractice claim
The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of:
-cabbage cabbage is a gas producing food that can cause colostomy problems with odor control and ballooning the ostomy bag, which can cause the device to seal and allow leakage
While serving as a leader, the nurse uses contingent variables recognized by the path-goal theory of leadership. Which actions of the nurse reflect the use of contingent variables? Select all that apply.
2) Setting clear expectations. 4) Eliminating obstacles to goal achievement. 5) Increasing opportunities for follower satisfaction.
somatoform disorders
A class of psychological disorders involving physical ailments with no authentic organic basis that are due to psychological factors.
A nurse manager is helping staff reach optimal functioning to enhance organizational functions. Which Gardner's task is reflected in this leadership behavior?
Achieving workable unity Achieving workable unity is one of Gardner's tasks for leading and managing. Nurse managers should help staff reach optimal functioning to enhance organizational functions. Nurse managers enact motivation by relating to and inspiring staff to achieve the mission of the organization and the associated vision. Affirming values is involved in assisting the staff in explaining organizational values and strengthening staff members to be more attuned to the organization. Envisioning goals involves creating a vision of how systems support client care objectives and assisting in enhancing the vision of clinical and organization performance.
The nurse is learning about the rules of leaders. Which actions of the nurse indicate effective implementation of these rules in the profession? Select all that apply.
Communicating in a simple language with followers Giving a chance to the followers to express their views Ensuring proper eye contact while communicating with followers
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may:
If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit. -if the device becomes full and is not emptied. it can pull away from the skin and leak
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?
Impaired neural functioning Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.
vasoocclusive crisis
Ischemia and pain caused by sickle-shaped red blood cells that obstruct blood flow to a portion of the body. Characterized by edema, imparied range of motion, and pain in the hands and feet resulting from the obstruction of the small blood vessels of the hands and feet
Metastatic carcinoma
Most common form of cancer involving the bone; affects vertebrae, ribs, pelvis, and skull most often
Restoritive Care
activities designed to assist the resident in reaching or maintaining his level of potential
jugular vein distention
bulging of the neck veins
transformational theory
leaders motivate others to behave in accordance with mutual values and empower others to contribute
A client is admitted to the high-risk unit in preterm labor. A loading dose of 6 g of magnesium sulfate over 20 minutes is prescribed, to be followed by 2 g/hr. Premixed stock is available with 40 g of magnesium sulfate in 1000 mL of D5W. At a rate of how many milliliters should a nurse set the infusion pump to complete the loading dose? Record your answer as a whole number. ___
mL/hra.450b.Use the "Desire over Have" formula to solve the problem, using ratio and proportion. An infusion pump is set in milliliters per hour; 150 mL is needed in 20minutes. There are 60 minutes in an hour; therefore 3 × 150 = 450 mL/hr
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is:
An unconscious means of reducing stress When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved
Lorazepam
Benzodiazepine Antianxiety
A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?
C. A listing of facts related to the incident as witnessed by the nurse when completing an incident report, only objective facts surrounding the incident should be reported. not opinion or speculation
A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding?
Chemical irritation to the tissues -These are signs of phlebitis; caused but irritating medications
The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are:
Less anxious and more aware of reality and therefore ready to learn Anxiety or anger associated with other stages of coping interfere with learning
orchiectomy
removal of the testes risks include- thrombophlebitis, pulmonary embolus, stroke
Contingent Variables
situational factors: variables that moderate the relationship between two or more variables
urinalysis
the examination of urine to determine the presence of abnormal elements
while taking a clients temporal artery reading temperature, the nurse places the probe flush on the client's forehead. what is the rationale behind this intervention?
to prevent the nurse from measuring ambient temperature
hematamesis
vomiting blood
Which statement made by a nurse indicates being an effective community opinion leader?
"I will try to build a society that treats males and females equally."
A registered nurse is teaching a student nurse about Gesell's theory of biophysical development. Which statement by the student nurse indicates the need for further teaching? Select all that apply.
"Proximodistal growth describes the sequence in which growth is fastest from the head down." "In the cephalocaudal pattern, growth starts at the center of the body and moves toward the extremities."
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider?
-assessment of skin turgor -administration of antiemetic drugs -replacement of fluids and electrolytes
Normal platelet count
150,000-400,000
when writing a disaster plan for implementation during a mass casualty incident (MCI) you should consider that what percentage of victims often require admission to the hosptial for further treatment ?
30 %
A nursing student is listing examples of healthcare services. Which scenario is an example of restorative care?
D) Visiting a private residence to perform maggot-aided debridement therapy of a client's wound
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned?
Methyldopa (Aldomet) Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications.
myocardial infarction
heart attack
A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?
-tubing injection port - nurse should clean the injection port cap of catheter drainage tubing with appropriate antiseptic, attach a sterile 5-ml syringe into the port and aspirate the quantity needed
A nurse leader is given an additional duty of nurse navigator. Which extra responsibilities does the nurse leader need to provide as a nurse navigator? Select all that apply.
Address barriers to care Provide psychosocial support Provide health education about the disease - a nurse navigator will help clients with serious chronic diseases by assessing, screening, diagnosing, treating, and follow up care.
Nuetropenia
An abnormally low count of a type of white blood cell (neutrophils)
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing?
Ascorbic acid (Ascorbicap) -it is necessary for the maintenance and formation of collagen, the major protein of most connective tissues
peristalsis
Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.
symptomatic ventricular defect (VSD)
Ventricular septal defect (VSD) symptoms in a baby may include: Poor eating, failure to thrive. Fast breathing or breathlessness
distention
a condition of being stretched, inflated, or larger than normal
bronchospasm
a contraction of the smooth muscle in the walls of the bronchi and bronchioles that tighten and squeeze the airway shut
trait theory
a leadership theory that holds that effective leaders possess a similar set of traits or characteristics
traction
a pulling force exerted on a limb in a distal direction in an effort to return the bone or joint to normal alignment
Methicillin-resistant Staphylococcus aureus (MRSA)
a strain of the bacterium Staphylococcus aureus that has become resistant to the antibacterial action of the antibiotic methicillin, a form of penicillin
diverticular disease
condition in which bulging pouches (diverticula) in the gastrointestinal (GI) tract push the mucosal lining through the surrounding muscle
colostomy
creation of an artificial opening into the colon
Thrombocytopenia
low platelet count
gastrostomy
making a new opening in the stomach -patient will be administered tube feedings
bone marrow aspiration
needle aspiration of bone marrow tissue for pathologic examination
hematuria
presence of blood in the urine
